CyberKnife - Hemicranial Meningioma

Successful CyberKnife Irradiation of 1000 cc Hemicranial Meningioma: 6-year Follow-up

Meningiomas are common benign tumors with accepted treatment approaches and usually don't challenge healthcare specialists. We present a case of a huge unresectable hemicranial meningioma, which was successfully treated with hypofractionated irradiation.

A male patient, sixty-two years of age, suffered for over 12 years from headaches, facial deformity, right eye displacement, right eye movement restriction, right-sided ptosis, and facial hypoesthesia. MRI and CT studies revealed an extended hemicranial meningioma. Prior to irradiation, the patient underwent four operations. Eventually, the tumor was irradiated with the CyberKnife in August 2009. Tumor volume composed 1085 cc. The mean dose of 35.3 Gy was delivered in 7 fractions (31.5 Gy at 72% isodose line comprising 95% of tumor volume). The patient was followed during six years and experienced only mild (Grade 1-2 CTCAE) acute skin and mucosa reactions. During the follow-up period, we observed target volume shrinkage for 17% (for 26% after excluding hyperostosis) and regression of intracranial hypertension signs.

Due to the extreme volume and complex shape of the tumor, spreading along the surface of the hemisphere as well as an optic nerve involvement, the case presented would not be generally considered suitable for irradiation, especially for hypofractionation. 

We regard this clinical situation not as a treatment recommendation, but as a demonstration of the underestimated possibilities of hypofractionation regimen and CyberKnife system, both of which are limited with our habit of conventional treatments.

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BRAIN METASTASIS

In many patients with brain metastases, the primary therapeutic aim is symptom palliation and maintenance of neurologic function, but in a subgroup, long-term survival is possible. Local control in the brain, and absent or controlled extracranial sites of disease are prerequisites for favorable survival. 

Stereotactic radiosurgery (SRS) is a focal, highly precise treatment option with a long track record. Its clinical development and implementation by several pioneering institutions eventually rendered possible cooperative group randomized trials. A systematic review of those studies and other landmark studies was undertaken. 

Most clinicians are aware of the potential benefits of SRS such as a short treatment time, a high probability of treated-lesion control and, when adhering to typical dose/volume recommendations, a low normal tissue complication probability. 

However, SRS as sole first-line treatment carries a risk of failure in non-treated brain regions, which has resulted in controversy around when to add whole-brain radiotherapy (WBRT). SRS might also be prescribed as salvage treatment in patients relapsing despite previous SRS and/or WBRT. An optimal balance between intracranial control and side effects requires continued research efforts.

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Success with Cyber Knife - Hepato Cellular Carcinoma

Hapato Cellular Carcinoma- Successful treatment with Cyberknife 

A 60 yr old gentleman was incidentally found to have a space occupying lesion in the liver  which was diagnosed as hepatocellular carcinoma in June 2013.

He underwent a resection of the lesion in July 2013.Follow up imaging showed a small residual lesion and hence he was started on Tab.Sorafinib from November,2013. But serial imaging showed
an increase in the size of the lesion. Biopsy of the lesion confirmed it to be hepatocellular carcinoma.

The various treatment options were discussed. The patient was not keen for surgery and due to the
proximity of the hepatic vein, RFA was also difficult. It was decided to give radio surgery with Cyber knife to the residual lesion. 

After fiducial placement for real time tracking of the lesion, a total dose of 40 Gy was delivered in 5 fractions. He underwent the treatment quite well with no difficulties. Follow up after 2 months imaging
showed a decrease in the size of the lesion with reduced activity of FDG uptake indicating good response to the treatment.

This is a case study discussion of Dr.Rathna who is a senior consultant , Radiation Oncology.

To know more about cyberknife kindly blog your comments or you can write to me at lakshmipriya_b@apollohospitals.com/9940675877